July 23, 2008 In resource-limited settings where tuberculosis is a major cause of mortality among HIV patients and where a multidrug-resistant TB epidemic is emerging, researchers are pressing for approaches to integrate TB prevention and treatment into HIV care and treatment.
"HIV programs have no option but to address TB vigorously to save patient lives, safeguard the massive investment in HIV treatment, and to curb the global TB burden," said Diane V. Havlir, MD, chief of UCSF's HIV/AIDS Division at San Francisco General Hospital's Positive Health Program and lead author of a special communication.
The authors propose several strategic approaches to reduce TB burden for HIV care and treatment programs. They include:
- TB Intensified Case Finding - Finding and treating TB promptly is the most effective TB control measure. Intensified case finding includes both active identification of TB among patients with HIV in care and screening their household members for active TB.
- Treating Individuals With Active TB -- The authors propose expansion of a care model whereby TB is treated by HIV programs. HIV care staff are trained to diagnose and treat a wide array of infections associated with HIV disease. "Tuberculosis should be no exception."
- Isoniazid Preventive Therapy - HIV programs may need to work with country policymakers to permit IPT administration, which in some countries is either against national policy or impossible because of the stringent requirements for the exclusion of TB before IPT initiation.
- Antiretroviral Therapy - ART is one of the most powerful weapons against TB. From the perspective of TB prevention, the earlier that ART is initiated, the less the risk for TB.
- TB Infection Control - One of the most challenging areas in TB infection control is the implementation of measures in both outpatient and inpatient health care facilities that will reduce the risk of TB transmission and protect health care workers. Tuberculosis infection control guidelines exist but are rarely implemented.
- TB Recording and Reporting - It is essential that HIV care programs adhere to TB reporting requirements. Standardized recording and reporting formats in accordance with national TB and AIDS control guidelines should be used.
- Joint HIV/TB Planning - The successful implementation of TB interventions in HIV services requires effective communication, coordination, and collaboration with TB control programs.
One highly recommended measure is intensified TB case finding. The most effective TB control measure is finding and promptly treating TB, according to the authors. Patients with HIV who are undergoing care should be screened for TB along with members of their household, and the HIV patients who have active TB should be treated for this disease within the HIV program. The authors note that because TB may be the disease that brings an HIV patient into care and there are many more clinics for TB than HIV, HIV patients with active TB often are treated in TB clinics and later referred to an HIV program.
The authors emphasize that TB infection control measures should be implemented in both outpatient and inpatient HIV care facilities so that TB is not transmitted in these settings. TB should be recorded and reported to national TB programs by HIV programs to ensure effective tracking of the TB epidemic, and there should be joint HIV and TB planning, they add.
The National Institute of Allergy and Infectious Diseases provided funding for the study.
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- Diane V. Havlir; Haileyesus Getahun; Ian Sanne; Paul Nunn. Opportunities and Challenges for HIV Care in Overlapping HIV and TB Epidemics. JAMA, 2008;300(4):423-430 [link]
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